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PCOS and Menopause: Beyond Hormones and Hot Flashes

How Does PCOS Change After Menopause?

PCOS does not go away once a woman enters menopause. Age-related PCOS changes were once considered a “medical black hole;” PCOS was unstudied prior to the last decade. It is argued that upon menopause, when a woman is no longer ovulating, PCOS no longer exists. According to the American Association of Clinical Endocrinologists Practice Guidelines, diagnostic criteria for women with PCOS after menopause does not exist. However, the limited research on PCOS in the aging woman shows changes that both improve her symptoms of PCOS and decrease her risk for chronic disease. PCOS is now known to have numerous metabolic risks that start early in adulthood and persist throughout a woman’s lifespan. This article discusses PCOS and its associated risk factors, how PCOS changes with age, and effective evidence-based treatment options.

Reproductive Changes

Numerous studies have found that testosterone levels in women with PCOS gradually decrease to normal-for-age levels, but that this decrease was slower than for women without PCOS. 

Levels of DHEA, the precursor to testosterone, remained higher after menopause in those with PCOS. This evidence shows that women with PCOS reach menopause perhaps 2 years later than do women without PCOS, due to higher and prolonged androgen levels.

Decreases in androgens have been shown to improve menstrual regularity, perhaps increasing the chances of conception in some women who struggled with infertility for years. In addition, hirsutism symptoms have been shown to persist or worsen after menopause, possibly from lifelong exposure to high androgen levels.

New Research Findings

Anti-Mullierian Hormone (AMH) is a marker of ovarian reserve. AMH levels have been shown to remain significantly elevated in older women with PCOS, which may be a more reliable diagnostic criterion for the condition than testosterone is, since AMH levels naturally decrease with age.

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Metabolic Changes with Age

It is now known that PCOS is a lifelong disease, although its manifestation changes as a woman approaches menopause.  Weight and metabolic changes tend to worsen with age. Women with PCOS are at higher risk for metabolic diseases post-menopause than are their age-matched peers. Additionally, the presence of PCOS increases the risk for endometrial cancer.

Up to 40% of women with PCOS will develop IGT or T2DM by the fourth decade of life. 

Compared to age- and weight-matched women, those with PCOS have a fivefold increased risk for T2DM over an eight-year period. There is a rapid progression of IGT to T2DM when PCOS is present. For this reason, the  have recommend annual screening for women with PCOS who have IGT, utilizing an oral glucose tolerance test (OGTT). AE-PCOS also recommends that all women with PCOS and normal glucose levels receive OGTT screening every two years.

Despite the associated risk factors for CVD among women with PCOS, evidence of CVD in this population is conflicting. Causes may include the large heterogeneity existing among members of this population, as well as a lack of gPCOS Nutrition Centerood studies.

Other Age-Related Changes

A 2017 meta-analysis suggests that when PCOS is present, stroke risk increases by 36% but the risk for all-cause mortality does not increase. The reason for increased stroke risk is unknown but the authors suggest that practitioners “aggressively screen patients with PCOS for stroke risk factors and initiate treatments.”

Bone Density

Studies on bone mineral density (BMD) and fractures in postmenopausal women with PCOS are lacking. Androgens are important for bone mass and may be protective against fractures and bone loss. Fracture rates were decreased in a large population of women with PCOS living in Denmark. More importantly, this study found that:

  • Fracture risk reduction was the same regardless of testosterone levels (high versus normal)
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Nutrition Management for PCOS After Menopause

Diet and lifestyle changes involving regular exercise, adequate sleep quality, smoking cessation, and stress reduction are recommended as the first-line approach to treating PCOS after menopause.

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Antioxidants Matter

Compared to women without PCOS, those with PCOS have higher levels of oxidative stress, insulin, and inflammatory markers.

Low levels of both magnesium and zinc have been found in women with PCOS. Magnesium and zinc are antioxidants that help to prevent oxidative damage and inflammation, and they also play a role in insulin regulation. For women with PCOS, supplementing with zinc and magnesium has improved their biomarkers of inflammation and oxidative stress, as well as their hormonal profiles.

Researchers have investigated the use of an anti-inflammatory diets in women with PCOS including the DASH Diet with favorable results in reducing levels of inflammatory markers cholesterol, blood pressure, and fasting blood glucose

These results show that women with PCOS benefit from diets high in fiber (both soluble and insoluble) as well as antioxidant-rich whole foods such as:

Nutrition Supplements for PCOS

Some nutrition supplements, such as myo and d-chiro inositol and the antioxidant n-acetylcysteine (NAC), have been shown to improve metabolic aspects of PCOS, working as well as if not better than metformin. Other supplements shown to improve aspects of PCOS include vitamin D, zinc, magnesium, and omega-3 fatty acids.

Vitamin B12 deficiency is a concern for older individuals. Long-term metformin use has been shown to reduce levels of vitamin B12. Women with PCOS who take metformin must have their vitamin B12 levels checked annually and supplement their diets with vitamin B12 if needed.

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Conclusion

PCOS is a lifelong condition with serious long-term health risks. The nutrition management for older women with PCOS should take into account the risk of long-term complications associated with this disease. Effective and aggressive treatment is needed, with interventions involving diet, nutritional supplements, lifestyle, and insulin sensitizers for older women with PCOS who have metabolic complications.

angela grassi PCOS dietiitian nutritionistAngela Grassi, MS, RDN, LDN, is the founder of The PCOS Nutrition Center, for which she provides evidence-based nutrition information and coaching to women with PCOS. Angela is the author of several books on PCOS, including PCOS: The Dietitian’s Guide, The PCOS Workbook: Your Guide to Complete Physical and Emotional Health, and The PCOS Nutrition Center Cookbook. Angela is the past recipient of The Outstanding Nutrition Entrepreneur Award, The Award in Excellence in Practice in Women’s Health, and The Award for Excellence in Graduate Research, from the Academy of Nutrition and Dietetics. Having PCOS herself, Angela has been dedicated to advocacy, education, and research of the syndrome. Click below to schedule a session with Angela to learn more about how nutrition coaching for PCOS can help you!

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References

Gunning MN, Fauser BC. Are women with polycstic ovary syndrome at increased risk for cardiovascular disease later in life? Climaceteric. 2017;2(3): 222-227.

Moran LJ, Misso ML, Wild RA, Norman RJ. Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis. Hum. Reprod. Update. 2010;16(4):347-363.

Harris HR, Terry KL. Polycystic ovary syndrome and risk of endometrial, ovarian, and breast cancer: a systematic review. Fertil Res Pract. 2016;2:14.

Rashidi BH, Gorginzadeh M, Aalipour S. Age related endocrine patterns observed in polycystic ovary syndrome patients vs. ovulatory controls: descriptive data from a university based infertility center. Arch Endocrinol Metab. 2016;60(5):486-491.

Schmidt J, Brannstrom M, Landin-Wilhelmsen K. Reproductive hormone levels and anthropometry in postmenopausal women with polycystic ovary syndrome (PCOS): a 21-year follow-up study of women diagnosed with PCOS around 50 years ago and their age-matched controls. J. Clin. Endocrinol. Metab. 2011;96(7):2178-2185.

Wild RA, Carmina E, Diamanti-Kandarakis E et al. Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: a consensus statement by the Androgen Excess and PCOS Society. J Clin Endocrinol Met. 2010;95:2038-2049.

Fenton A, Panay N. Management of polycystic ovary syndrome in postmenopausal women: a medical black hole. Climacteric. 2008;11(2):89-90.

Carmina E, Campagna AM, Lobo RA. A 20-year follow-up of young women with polycystic ovary syndrome. Obstet. Gynecol. 2012;119(2 Pt 1):263-269.

Markopoulos MC, Rizos D, Valsamakis G, et al. Hyperandrogenism in women with polycystic ovary syndrome persists after menopause. J. Clin. Endocrinol. Metab. 2011;96(3):623-631.

Puurunen J, Piltonen T, Morin-Papunen L, et al. Unfavorable hormonal, metabolic, and inflammatory alterations persist after menopause in women with PCOS. J. Clin. Endocrinol. Metab. 2011;96(6):1827-1834.

Boudreaux MY, Talbott EO, Kip KE, Brooks MM, Witchel SF. Risk of T2DM and impaired fasting glucose among PCOS subjects: results of an 8-year follow-up. Curr Diab Rep. 2006;6(1):77-83.

Salley KE, Wickham EP, Cheang KI, Essah PA, Karjane NW, Nestler JE. Glucose intolerance in polycystic ovary syndrome–a position statement of the Androgen Excess Society. J Clin Endocrinol Metab. 2007;92(12):4546-56.

Zhou Y, et al. Association between polycystic ovary syndrome and the risk of stroke and all-cause mortality: insights from a meta-analysis. Gynecol Endocrinol. 2017;1-7.

Rubin KH, Glintborg D, Nybo M. Fracture Risk Is Decreased in Women With Polycystic Ovary Syndrome: A Register-Based and Population-Based Cohort Study. J Bone Miner Res. 2016;31(4):709-17.

Maktabi M, Jamilian M, Asemi Z. Magnesium-Zinc-Calcium-Vitamin D Co-supplementation Improves Hormonal Profiles, Biomarkers of Inflammation and Oxidative Stress in Women with Polycystic Ovary Syndrome: a Randomized, Double-Blind, Placebo-Controlled Trial. Biol Trace Elem Res.2017:1-8.

Salama A, Amine E, Salem H, et al. Anti-Inflammatory Dietary Combo in Overweight and Obese Women with Polycystic Ovary Syndrome. N Am J Med Sci. 2015l; 7(7): 310–316.

Azadi-Yazdi M, Karimi-Zarchi M, Salehi-Abargouei A. Effects of Dietary Approach to Stop Hypertension diet on androgens, antioxidant status and body composition in overweight and obese women with polycystic ovary syndrome: a randomised controlled trial. J Hum Nutr Diet. 2017;30(3):275-283.

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Comments (3)
  • Susie

    April 11, 2019 at 5:18 pm

    My story of PCOS and menopause. Period began at age 10 1/2 yrs old. Acne and very oily skin began age 11/12. Always was 10 lbs heavier than peers. Diagnosed at 18 with PCOS…was told polycystic under-developed ovaries, slightly tipped uterus, and that I’d never have kids. Devastating to hear! Weight gain was easy at 24. Through a low fat diet and exercise the weight came off within 4 months. By 31 I was up 45 lbs again. A low fat diet and meds took the weight off. By 33 I had regained the weight. At 34 I killed myself with diet and Tons of exercise, asrobic and weights. 6 mos later it didn’t look like I ever exercised a day in my life, the weight wouldn’t budge! At 36 I found a diet Dr who put me on meds and a low carb diet. The weight came off fast. Despite numerous gynecologists through the years and informing of my PCOS diagnosis with each one, the only thing any of them said was not to worry about conceiving until I was ready to have kids. I had no clue the weight issues and lifelong acne was part of the PCOS! Until, that is, I met that last diet Dr. I discovered the connection through something he said. I kept the weight off until 42, then I struggled with maintaining my weight. Any little cheat from the diet and I’d gain 2 lbs and it’d take a month to get off. At 41 1/2 yrs old I also saw some peri-menopause symptoms arise. A friend alerted me when I expressed some huge hair loss concerns, warm spells, and extreme hunger for no reason. My periods and pms symptoms changed, too. I had major pain the first few days of each period, my cycle was random, breast tenderness increased and changed, my acne worsened in ways I was not prepared for, and embarrassingly so! It nearly turned me into a recluse. I always had embarrassing acne but never multiple (7-9) cystic blemishes at once. At 46 I discovered I had an enlarged misshapen uterus full of fibroids. Ah, the pain explained! By 47 I was plucking 80-90 chin hairs (no joke), and you’d never know I had laser hair removal in my unmentionable region at 33. Ugh! Now at nearly 49 and almost in menopause, it’s been a long road! I cannot get an ounce of weight off (had several sudden 10 lb gains) but the acne has subsided considerably (not gone), my sex drive is null and void. I feel … old. The only silver lining was I never had more than a couple major hot flashes, I only got random warm spells, had one week with tons of them though. No night sweats either….whew! So, in my experience, my PCOS symptoms worsened hugely through the long haul of peri-menopause. .With my acne now under control (by the way, nothing a dermatologist tried over the years ever worked, and yes I was on birth control for nearly 20 yrs), all I currently hope for now is something that will get the weight off! I always wanted to be a mother but never had children, we never tried .. but, that’s another story.

  • Angela Grassi

    April 12, 2019 at 8:00 am

    Susie, thank you for sharing your story. Unfortunately, you are not alone in your struggles with PCOS. This is why we need early detection and treatment and ultimately, a cure so those with this common condition do not have to suffer anymore.

  • Sherrill

    May 9, 2019 at 7:21 am

    Thank you for the information on this horrible disease . I’m 55 & my Dr is taking me off Diane 35 which has been a life saver for me. I don’t know why they want to cause me more trouble when everything is now balanced out. I doubt I’ll survive without the pill.

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